Scalpel versus no-scalpel incision for vasectomy
Compared with the traditional incisional method, no-scalpel vasectomy results in less bleeding, haematoma and pain during or after the procedure. It takes less operation time and vasectomized men are able to resume sexual activity more quickly. The no-scalpel technique is currently used in more than 40 countries.
RHL Commentary by Xiaozhang L
1. EVIDENCE SUMMARY
The reviewers identified 55 potentially relevant trials, but only two trials met the inclusion criteria. The review excluded nonrandomized controlled trials and those lacking a comparison between the incisional and the non-incisional (no-scalpel) technique.
Compared with the traditional incisional method, no-scalpel vasectomy resulted in less bleeding, haematoma and pain during or after the procedure. Also, there were fewer cases of infection, the procedure took less operation time, and vasectomized men were able to resume sexual activity more quickly. The absence of any demonstrated benefits of the no-scalpel technique reported in one study (1) could have been due to surgeons lacking experience with the no-scalpel technique or small sample size and high loss to follow-up.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Sterilization is the most widely used contraceptive method worldwide. According to United Nations estimates, in 2005, 262 million women of reproductive age were using sterilization as their method of contraception. Of these, 225 million relied on female sterilization and 37 million on vasectomy, accounting for 34% and 5.6%, respectively, of all contraceptive use (2). While female sterilization is far more common than male sterilization, as a procedure vasectomy is safer, simpler, about half the cost of female sterilization, and probably more effective.
Traditional incision vasectomy has been used for half a century and has proved to be a method that is simple, inexpensive and effective. The surgical incision, however, accounts for most of the operation-related complications, in particular bleeding, haematoma, and infection.
Since the advent of vasectomy, various attempts have been made to make the procedure safer, easier to perform, more effective and more acceptable. No-scalpel vasectomy was developed in China by Dr. Li Shunqiang with the aim of reducing men’s fear related to the incision and increasing vasectomy use in China. Since 1974, over 10 million Chinese men have undergone vasectomy by the no-scalpel technique.
No-scalpel vasectomy is less invasive than the incision approach because tissue trauma or blood vessel injury caused by sharp or blind dissection is avoided. It is a breakthrough advance in vasectomy practice with the main clinical advantage being a low surgical complication rate, especially haematoma and infection.
2.2. Applicability of the results
There is no biological reason to expect that trial outcomes could differ in different settings. However, all surgeons operating with the technique need to be trained appropriately to get consistent results. For those who are already skilled in traditional incisional vasectomy technique, practice with 15 cases is generally required to develop proficiency in the no-scalpel method.
The effectiveness rate of no-scalpel vasectomy has been reported to be 98% at 24 months postoperatively (3). Based on available evidence no-scalpel vasectomy is regarded as the safest surgical approach for isolating and exposing the vas for purposes of vasectomy (4). It is the method of choice for surgeons who perform vasectomy on a regular basis.
2.3. Implementation of the intervention
The no-scalpel vasectomy technique has helped to increase the acceptability of vasectomy worldwide. In Latin America, the use of vasectomy for contraception has increased fourfold in the past decade. This increase has been attributed to the no-scalpel method being made the standard technique for all vasectomy operations. In addition, the countries of that region have promoted vasectomy via mass media campaigns and made no-scalpel vasectomy available at the primary-care level, providing ongoing supervision and technical support to service delivery sites (5).
The Indian government launched a national no-scalpel vasectomy project in 1998 in collaboration with the United Nations Population Fund (UNFPA) to promote male participation in contraception and arrest the declining trend in male sterilization. Under the project, 4000 surgeons were trained, among whom 1300 were certified service providers. There are now 100 no-scalpel vasectomy trainers across various states in the country. The prevalence of vasectomy in the national contraceptive method mix increased from 0.7 % in 1997 to about 3% in 2003. Today India is one of the leading nations in the world with regard to the use of no-scalpel vasectomy, as indicated by a high number of hits on an Indian no-scalpel vasectomy web site called NSV Surgeons India (http://www.nsvsi.com/) (6).
In the Islamic Republic of Iran, there was no demand for vasectomy prior to introduction of no-scalpel vasectomy in 1993. Between 1993 and 2004, 500 training courses were conducted in public sector institutions, which helped to train 460 medical doctors in the technique. During the same period, an estimated 375 000 Iranian underwent the procedure, raising the prevalence of vasectomy from 0% to 3.5% in national contraceptive mix (7).
No-scalpel vasectomy is expanding options for male involvement in family planning in the Philippines. Effort of the "Cooperative Movement for Encouraging No-scalpel Vasectomy" has demonstrated that men are willing to assume the responsibility for family planning if they are given the opportunity to do so. The number of men choosing vasectomy as a method of family planning rose from 20 per year in 2000 to about 2000 per year in recent years (8).
The no-scalpel technique is currently used in more than 40 countries (9) and is becoming the standard method around the world (10).
3. RESEARCH
A trial in 1999 (11) provided for the first time strong evidence that the no-scalpel approach resulted in low rate of early complications such as bleeding, haematoma, pain during or after the procedure, and infection, compared to the traditional incision technique. A second well designed prospective randomized controlled trial would make the evidence even stronger.
No-scalpel vasectomy is a new surgical approach for isolating and exposing the vas deferens. Once the vas has been exposed, it can be occluded in operator’s preferred method (such as ligation, cautery, clips, or laser, used alone or in combination). Little is known about the long-term effectiveness of the different vas occlusion techniques and which technique is more effective than others in decreasing the risk of long-term complications such as chronic epididymal pain syndrome. Furthermore, more research is needed to determine which is the most effective and safest surgical vasectomy technique.
The future studies would be strengthened by the standardization of follow-up protocols and statistical analysis methods. Research to compare the relative costs of incisional vasectomy and no-scalpel vasectomy would also be useful.
References
- Christensen P, al-Aqidi OA, Jensen FS, Dorflinger T. Vasectomy: a prospective, randomized trial of vasectomy with bilateral incision versus the Li vasectomy. Ugeskr Laeger 2002;164:2390-4.
- World Contraceptive Use 2005. New York: United Nations Department of Economic and Social Affairs; 2005.
- UNDP/UNFPA/WHO/World Bank Special Programme of Research. Development and research Training in Human Reproduction. Annual Technical Report 1995. Geneva: World Health Organization; 1996.
- Labrecque M, Defresne C, Barone M, St-Hilaire K. Vasectomy surgical techniques: a systematic review. BMC Med 2004;2:21.
- Program for Appropriate Technology in Health. Choosing male sterilization. Outlook 2004;21.
- Kaza RC. No-scalpel vasectomy: an overview. Journal of the Indian Medical Association 2006;104(3):4.
- Country report on the population and family planning program in the Islamic Republic of Iran. Tehran: Ministry of Health and Medical Education; 2003.
- Male Involvement for Safe Motherhood Enterprise. Report of CMEN, January 2007, Philippines
- No-scalpel vasectomy: an illustrated guide for surgeons. Third Edition. New York: EngenderHealth; 2003.
- Family planning: a global handbook for providers. Baltimore and Geneva: World Health Organization and Johns Hopkins Bloomberg School of Public Health/ Center for Communication Programs (CCP), INFO Project; 2007.
- Sokal D, McMullen S, Gates D, Dominik R. A comparative study of the no scalpel and standard incision approaches to vasectomy in 5 countries. The Male Sterilization Investigator Team. J Urol 1999;162:1621-5.
This document should be cited as: Xiaozhang L. Scalpel versus no-scalpel incision for vasectomy: RHL commentary (last revised: 27 July 2009). The WHO Reproductive Health Library; Geneva: World Health Organization.